Healthcare Provider Details

I. General information

NPI: 1346202512
Provider Name (Legal Business Name): LAKE HOSPITAL SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 08/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36000 EUCLID AVE
WILLOUGHBY OH
44094-4625
US

IV. Provider business mailing address

PO BOX 714110
COLUMBUS OH
43271-4110
US

V. Phone/Fax

Practice location:
  • Phone: 440-354-1618
  • Fax: 440-354-1848
Mailing address:
  • Phone: 440-274-5035
  • Fax: 440-716-8608

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL KITTOE
Title or Position: CFO
Credential:
Phone: 440-354-1952